I started meds with a viral load of greater than 750,000 with Viracept, d4t, 3tc and Viread but have decided not to take a chance with losing fat so want to drop the D4t.

What do you think of the original combo and what do you think of the one I want to change to?

After 28 days of treatment my vload was 14,000.

Thank you so much.

Response from Dr. Cohen

Well, by now hopefully you've made whatever change you have made, and seen if your viral load continues to drop. But let's explore this a bit to see what the issues are, and perhaps you can let us know what did occur, since we cannot always predict what will happen

First. It is fair to state that for those who start treatment with a viral load well over 100,000, a triple regimen based on viracept has been shown repeatedly to not be our most successful choice. We have seen several studies with consistent results that show how alternatives to viracept lead to more reliable rates of viral suppression. These alternatives have been either a boosted protease inhibitor (Kaletra) or even a nonboosted PI (Such as Reyataz or Lexiva). But if you wanted to stay with viracept as the protease inhibitor, one approach might be to add a 4th drug to this combination as you have done. And you are right, the information we have so far does support that there is less lipoatrophy or fat loss on abacavir than on d4T. So the substitution does make some sense.

The only hesitation is this. There was a recent study that combined only the nucleosides you are considering epivir, ziagen and viread. And these three alone didn't do well in terms of viral suppression. And one prediction that has been proposed as to why this didn't work well is a proposed concern albeit one without any data to support it that the combination of abacavir and viread has some "antagonism" inside cells so that these two are less effective than other standard combinations. Now, this antagonism might lead to some hesitation about using it in other combinations when there are other more proven options. For example, you might consider replacing the viracept with any of the "boosted" PIs or even one of the unboosted PIs -- lexiva or reyataz that have shown reliable efficacy even for those with high baseline viral loads. Or use the nonnucleoside Sustiva since it too has shown consistent viral suppression at high viral loads. This would allow you to rely on just two nucleosides plus a more reliable "third drug", instead of three nucleosides (with their unlikely and still only theoretical concerns) plus a PI that has less power at high viral loads.

Of course by now you might have your month 3 viral load and it may already be below detectable so these cautions may not longer be of concern. That is key to our field which is that there remain many uncertainties and approaches that we take that might work out, even though there are reasons to be cautious about them. Perhaps you can write in with some follow up about what happened?

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